(IJACSA) International Journal of Advanced Computer Science and Applications,

Vol. 12, No. 2, 2021

Development of a Virtual Pet Simulator for Pain and

Stress Distraction for Pediatric Patients using
Intelligent Techniques
Angie Solis-Vargas1, Iam Contreras-Alcázar2 Jose Sulla-Torres3
Escuela Profesional de Ingeniería de Sistemas Escuela Profesional de Ingeniería de Sistemas
Universidad Nacional de San Agustín de Arequipa Universidad Nacional de San Agustín
Arequipa, Perú Arequipa, Perú

Abstract—Pediatric medical procedures are often stressful In a virtual environment, different types of things or virtual
and painful for children, so they can resist and make the work of objects can be included; one type of these are pets. Virtual
doctors and nurses a little more complicated. This research aims pets are common in the domain of children's games, where
to develop a virtual pet simulator to distract pediatric patients children play with the virtual pet and often interact with it via
from pain and stress using smart techniques. The methodology a button or touch interface [5].
used is SUM. The primary data for the development of the
simulator were gravity, the player's position, the speed, and the In Peru, virtual environments and therapies with pets are
mass for the calculation of the predictive physics in the toy to scarce concerning the distraction of pain and stress of
interact with the pet. As part of the intelligent techniques, the A- pediatric patients during stressful or painful medical
star algorithm was used for the pet to follow the user and the procedures. It is known that a virtual environment can be of
flocking algorithm to have a natural behavior of a group of different types or modalities, one of them being those that
animals and thus have a higher immersion level. Trials were include virtual pets. So, will a virtual pet simulator be able to
conducted with pediatric patients where those who made use of distract pediatric patients from pain and/or stress during
the virtual pet simulator during the medical procedure felt less medical procedures using a virtual environment?
pain and stress than those who did not try the simulator.
Therefore, it is highly recommended to use alternatives such as This study seeks to help pediatric patients who need a
the one developed to reduce pain and stress in pediatric patients. distraction from both the pain and/or stress that they suffer
during medical procedures. Consequently, the goal is to
Keywords—Virtual pet; pediatric patients; pain; stress; smart develop a virtual pet simulator to distract pediatric patients
techniques; A-star algorithm; flocking algorithm from pain and stress during medical procedures using a virtual
environment and smart techniques, as these can help improve
I. INTRODUCTION the pediatric patient experience and assist them. To avoid
Pain is an emotional and unpleasant experience that the trauma from high pain medical procedures and even avoid
pediatrician often encounters in his daily activities with his scarring pediatric patients during simple medical procedures.
patients. To treat pain and anxiety in the best way is to avoid
them. Therefore, it is essential to try to avoid anxiety and To do this, the SUM methodology for video games was
stress that causes painful sensations [1]. used to develop quality games in defined times and costs. The
methodology goes through five phases: Concept development
Child distraction appears to be the most widely used phase, planning phase, development phase, beta phase, and
behavior management technique during medical procedures closing phase. Tools like Unity and Blender were also used.
[2]. Pet therapy can also be used to distract pediatric patients Besides, intelligent techniques such as the A-star algorithm
in stressful or painful situations. Studies show that children were applied so that the pet can follow the user and the
who interact with therapy pets, typically dogs, show increased flocking algorithm to have a natural behavior of secondary
coping skills and reduced anxiety levels. [3]. fauna, and thus the level of immersion is better.
A recent technological advance that can be an attractive The article has more sections which talk about the
distraction is virtual reality [4], which uses virtual following: Section II talks about the related works that
environments. Virtual reality immersion systems are also provided information for the development of the virtual pet
known to allow the user to interact with the computerized simulator. Section III contains the materials and methods
environment they are viewing and the feasibility of using developed for the development of the virtual pet simulator.
these computerized environments to reduce anxiety and pain Then in Section IV, we have the results obtained when using
associated with an invasive medical procedure in children with the developed simulator. In Section V we have the conclusions
Cancer [4]. obtained after analyzing the individual results, and finally, we
have in Section VI the future works to be developed.

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II. RELATED WORK Like pain, stress can also be measured using scales. Among
the main ones are:
This section reviews work related to pain management,
non-drug therapy, pet therapy, virtual reality for pain in medical  Visual analog scale (VAS): VAS is also used to
procedures, and virtual pets. measure anxiety and consists of a horizontal line of 10
cm with a connection of two points to each other,
A. Pain Treatment where 0 is equivalent to "without worry or anxiety"
The best treatment of pain and anxiety will be to avoid and 10 indicates "the worst worry or anxiety" with
them by promoting prevention, anticipating the pain produced opposite facial expressions joined along the same line.
by diseases or procedures. It is also essential to a void anxiety The child is asked to mark the point that best represents
and stress caused by the painful sensation [1]. To do this, you the anxiety he feels [9].
have to know how to value pain. In pediatric patients, it is
complex to assess pain since they have a limitation or  The facial image scale (FIS): It was developed to
impediment to express, transmit or specify their pain assess dental anxiety status in children. It consists of 5
(location, intensity, characteristics), and it is even more so faces ranging from very happy to very unhappy, which
while the age of the pediatric patient is younger [6]. children can easily recognize [10].
To assess pain, it is useful in the emergency department to B. Non-Pharmacological Treatments
consider the child's process, changes in physiological It has been shown that the reduction of pain and distress
parameters (increased heart rate and respiratory rate, cold skin, can be alleviated and that some simple, non-pharmacological
increased sweating, vasoconstriction of the skin), and the techniques can alleviate the fear they cause. For example, ice
scales pain assessment. Different scales try to objectify the or vibration therapy can also help distract patients during
intensity of pain according to the age of the child. For those painful procedures. Pediatric pain relief devices in the shape
over three years of age, subjective scales are used. Ages 3-6 of animals or insects are visually appealing to children for
years old: color scales or facial drawings. Ages 6-12: sale. Placed on your skin, they provide a cooling or vibrating
numerical, visual analog, or color scales [1]. effect that helps numb the injection pain. Pet therapy can also
be used to distract pediatric patients in stressful or painful
There are types of pain which we will mention below:
situations [3].
 According to the intensity of the pain: There is mild
Sampson and Renee [3] mention some examples of
pain, which usually will suffice an analgesic drug
distraction techniques for pediatric patients according to their
administered orally, and moderate pain that may be
age such as the calming effect of wrapping to which babies
necessary drug combinations and use, in addition to an
react well, soap bubbles or hide-a-face play that works well
analgesic, an anti-inflammatory, or a minor opioid [1].
for young children, cartoons for preschool children, audio
 According to the pain duration: There is acute pain, visual distractions for older children or teenagers, or also
which is pain directly related to a temporary injury and doing use of pet therapy for distract pediatric patients from
usually lasts for a short period (<6weeks). Also, stressful or painful situations.
chronic pain persists for a period longer than six C. Pet Therapies
weeks, often for months or years [7].
Animal-assisted therapy, also known as "pet therapy," is
 Pain from therapeutic, diagnostic procedures: the general term that refers to both animal-assisted activities
Currently, multiple procedures require pseudo- and animal-assisted therapies [11]. The dog is ideal because he
analgesia techniques. It is necessary to assess in these is more dependent on the human being and comes to learn and
cases the degree of pain and anxiety that is going to be obey [12]. Studies show that children who interact with
induced, to anticipate it [1]. therapy pets, usually dogs, show increased coping skills and
Just as there are types of pain, there are also forms of pain reduced anxiety levels [3]. Besides, Guha [13] mentions that
measurement such as scales, which are presented below [8]: the calming effects of animals are especially valuable with
children.
 Visual analog scale (VAS): Measures pain intensity
In order to be able to carry out the therapies with pets,
through a markerless line with lower or higher
Sampson and Renee [3] mention that the policies and
endpoints for pain intensity. This type of scale is used
procedures of the hospital that uses this type of therapy must
in school-age children.
be followed, in addition to the approval of the parents because
 Numerical Rating Scale (EN): This scale is a variation any type of contraindication must be ruled out such as
of EVA. Use numbers (0-10 or 0-100) to rate the pain. allergies or the possibility of bacterial contamination
This type of scale can be used in children seven years
D. Virtual Reality for Pain in Medical Procedures
and older.
Virtual reality is useful in providing relief from acute and
 Face, legs, activity, crying, and comfort (RPALC): procedural pain and can help provide a corrective
This scale evaluates distressing behaviors in five psychological and physiological environment to facilitate
categories (face, legs, activity, crying, and comfort). It rehabilitation for pediatric patients suffering from chronic
is used to measure acute pain in children two months to pain. Furthermore, virtual reality therapies that incorporate
7 years. body movement tracking allow for greater interactivity [7].

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A large body of evidence supports the efficacy of the game, a virtual pet will be presented in the first instance;
immersive virtual reality in reducing pain, anxiety and stress To be exact a dog, the user will be able to interact with it in
among pediatric patients undergoing burn care or cancer almost the same way as with a real one, that is, they will be
treatments, as it provides a means of human / human-computer able to: feed it, pet it and play with it.
interaction, in which a human becomes an active participant in
a virtual environment created through a head-mounted display. What features does the simulator have? The simulator has
Besides, by using virtual reality, the user actively participates the following:
in a virtual environment since real time changes with the  Be attractive in the eyes of children.
user's movements [14].
 Be a visual and auditory distractor.
E. Virtual Pets
 Be interactive by using the pet.
According to Lin, Faas and Brady [15] a virtual pet is a
type of agent that can be realistic or also abstract that is found The pet was chosen to be a dog because children have a
in video games or virtual reality environments, they also better interaction with them, as already mentioned in
highlight that people can have virtual pets in addition to or Section II of the article. Once the simulator's characteristics
instead of a real pet for company, amusement or for simple were established, the story of the game or simulator was
distraction. developed, which is simple. It is a parallel world away from
the anguish where the user can have fun with a lovely pet,
Virtual pets are common in the domain of popular
distracting him from his fears.
children's games, where children play with the virtual pet and
often nurture it through a button or touch interface, although Finally, the simulator setting was designed, which has a
more advanced interfaces feature gesture and speech semi-forest, since it has a good number of trees but not too
interaction such as the game Kinectimals (Microsoft Xbox many to block the sunlight or generate too many shadows that
360) or EyePet (Sony Playstation 3) [5]. could scare the user (pediatric patient). Flowers, grass, and
stones were also placed to give a more rustic atmosphere.
Studies have shown that using and interacting with virtual
Finally, some villages were also located to avoid a feeling of
pets to prevent the treatment of different diseases works quite
being asked or of loneliness.
well with children [5]. The Mixed Reality Virtual Pets system
to reduce childhood obesity developed by Johnsen et al. [5] B. Phase 2: Planning
turned out to be very reliable, and the study was a resounding In this section, the development team members' roles for
success despite having minimal game content, compared to the rest of the project were defined. The number of iterations
much more elaborate entertainment games, the virtual pet performed was also determined, and the milestones that had to
managed to motivate the treatment group of children who be met were specified. In the same way, the objectives to be
exercised significantly more than his peers in the control achieved to complete the project were defined. Finally, the
group. characteristics of the video game were specified.
All these reviews of the related works have served to
establish the basis for the virtual pet simulator's development
proposal for pediatric patients.
III. MATERIALS AND METHODS
The SUM methodology has been chosen for its advantages
in developing video games, which is divided into phases and
goes hand in hand with a risk management document. To
better understand the scope of this project using the SUM
methodology, the following diagram was followed, which can
be seen in Fig. 1. The diagram has 5 phases, which we will
talk about and explain what was developed in each of them to
achieve the final product, i.e. the virtual pet simulator. All
phases are accompanied by risk management.
A. Phase 1: Concept
In this phase, the project concept's development was
carried out; in other words, the vision, genre, classification,
characteristics, history, and setting of the simulator. This
game's vision is to provide a virtual pet that provides
entertainment to pediatric patients, and its genre is a
simulation.
Then the classification was continued: type E (Everyone), Fig. 1. SUM Methodology Diagram Designed by Acerenza et al. (2009)
that is, for everyone since it is a simulator for children. The [16].
gameplay of this simulator is as follows: When the user starts

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It was determined that the project would have three was carried out as seen in Fig. 7 and a plate of food as seen in
milestones which were developed in 17 weeks; therefore, a Fig. 8 using the Blender tool. It can be seen that the different
schedule was also developed. To better manage the project, models’ figures are quite simple and with basic colors because
the Trello tool was used to update the objectives or tasks that children like simple shapes and attractive colors, so they were
were concluded. As mentioned above, in this section, the modeled based on said analysis.
objectives of the project were defined, which are:
 Generate a relaxed setting with a semi-forest
environment.
 Generate a wide area for a good movement.
 Generate or obtain the model of a virtual dog.
 Generate functionalities with which you can interact
with the virtual dog.
 Find and play calm and entertaining music for children.
 Insert sounds of interaction.
Fig. 2. Home Tab.
C. Phase 3: Elaboration
For the development of this project, it was divided into
three stages. Stage 1 was the simulator analysis. For stage 2,
the corresponding design was carried out, and finally, it
culminates in stage 3, where the entire simulator
implementation was carried out.
In the analysis stage, functional and non-functional
requirements were defined. Below are some of the
functionalities that were defined for the development of the
project:
 The system will have the display function by using the
first-person camera since the child must be able to see Fig. 3. Virtual Dog Feeding.
the pet because it is the main point of distraction.
 The system will have the interaction function when the
child uses a controller to pet the pet.
 The system will have the functionality of
displacement, which will be given through a command.
 The system will have the object manipulation
functionality that will allow the child to interact with
objects within reach in the area, such as balls,
branches, or others to play with the pet.
 The system will have multimedia functionality since it
will require sound or music to relax and distract the Fig. 4. Play with the Virtual Dog.
child more efficiently.
In the design stage, the project's sketches or mockups were
made, which can be seen in the following figures. In Fig. 2,
the game start tab is shown, which has the game title plus a
button to start the game. Fig. 3 shows how the virtual dog is
fed. In Fig. 4, it is shown that the user can take objects and
throw them for the virtual dog to bring them back. In Fig. 5, it
is shown that it is possible to interact with the virtual pet, that
is, to caress it.
In this stage, the acquisition and/or creation of the
necessary assets for the simulator implementation was also
carried out. The asset of a 3D dog, quite friendly and
attractive for children, was acquired from the Unity Asset
Fig. 5. Interaction with the Virtual Dog.
Store as seen in Fig. 6, and the creation of assets of a toy bone

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Fig. 9. Virtual Terrain using the Gaia Tool.

For the creation of scripts, the C # programming language

was used since this language uses Unity. The launch script
was developed, which allows the user to take a specific object
from the stage and throw it; for this, gravity and the masses of
the objects were taken into account to give them weight. The
launch is based on the parabolic movement, and the prediction
of the trajectory consists of the following elements: starting
Fig. 6. Asset Virtual Dog. position in three dimensions based on time ( ̅ ); shooting
position in three dimensions ( ̅ ); output speed ( ); direction
the toy was fired ( ̅); the length of time since the toy was
released ( ); and gravity ( ̅ ) which in this case has a value of
9.81 m/s. The corresponding formula can be seen in (1) with
the active components.
̅
̅ ̅ ̅ (1)
In Fig. 10, you can see a cube, representing the toy (first
part of development, the toy had not been modelled yet), being
thrown openly on the stage; it is necessary to emphasize that
the player can pick up this object, the longer he holds it, he
will throw it; differently, it also depends on the mass of the
Fig. 7. Asset Toy Bone. rigid body component.
The launch script was made following the suggestion in
Tuto_DrawTrajectory [17], where you can see the initial
position of the toy with the applied force, through a loop "for"
begins to go through and updates the points where the toy will
go. Gravity is also applied based on the Unity game engine's
physics component along with its time, as can be seen in
Fig. 11.

Fig. 8. Asset Food Plate.

In the implementation stage, the development of the

scenario and different scripts in Unity was done. For the
creation of the virtual terrain, the Gaia 2.0 tool was used; it Fig. 10. Toy Launch.
helped speed up the development process a bit and generate a
good quality scenario. The simulator scenario with that tool is
presented below in Fig. 9. A forest was created in order to
create a natural and relaxing environment because medical
centers have unattractive rooms for children, even the fact of
seeing a hospital, already begins to scare them, so the end of
the virtual scenario of a forest, is to change the environment
together with the background music, and thus generate
tranquility.
Fig. 11. Toy Launch Script.

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For the smart part, the Pathfinding A-star algorithm was

used, which is probably the most popular path search
algorithm in artificial intelligence games [18]. The A-star
algorithm was imported as a library to the virtual pet
simulator in Unity. It is a generic search algorithm that can be
used to find solutions for many problems, including route
search. For route finding, the A-star algorithm repeatedly
examines the most promising unexplored location it has seen.
When a location is scanned, the algorithm terminates if that
location is the target; otherwise, it takes note of all the
neighbors at that location for further exploration. Fig. 14. Scene using Flocking.

The Pathfinding A star algorithm also made the virtual pet The Flock script is in charge of performing the flocking
follow the bone toy, as shown in Fig. 12. The Pathfinding A- behavior of several copy objects that are asked to generate
star library was implemented throughout the scenario; each according to the type of prefab assigned using the relationship
node's size is one, since the problem was recognizing the between neighbors of the FlockUnit script; that is, if it is
terrain, specifically the houses, furthermore, it can be seen that assigned a bird prefab and it is instructed to generate 100
the blue color is the space where the pet can move; near copies, then the Flock script will generate 100 bird copy
buildings there is no such color because it should not make prefabs, each of which will contain a behaviour given by the
sense for the pet to walk between the walls. The green line FlockUnit script that was assigned to the original prefab, and
represents the shortest path of the grid drawn by the algorithm. thus all the copies interact with each other as one giving the
The terrain is quite large because it has been created with Gaia desired flock effect.
2.0, so the library's recognition dimensions had to be enlarged
quite a bit and wait for it to recognize all the structures for the A life bar was also added using the Canvas tool, a tool
tour, which is shown in Fig. 13. already included within Unity. The life or energy bar
represents the energy that the virtual pet has to be able to play
The Flocking algorithm was also used, to generate a more with the user. If the life bar reaches the minimum, that is to
natural environment and with more significant nature, such as say 0, and if the toy is out of reach, then the pet will lie down
birds flying over a clear sky or a few butterflies flitting and rest until it is fed.
through the field, as can be seen in Fig. 14. The Flock and
FlockUnit scripts were used for this algorithm. FlockUnit is in D. Phase 4: Beta
charge of giving individual flock behavior to a prefab In the first version, it was obtained that the virtual pet
assigned to it by the script; that is, it controls the cohesion, pursues an object using the Pathfinding A star algorithm, the
separation, and alignment components of a single prefab, and object that the virtual pet follows can be taken by the user and
in case it has neighbors, that is, copies, it relates them to each thrown. It was also possible to obtain a vast and natural
other. scenery using the Gaia 2.0 tool since secondary nature such as
flowers and trees were added. The flocking algorithm was also
used to give it a more natural and immersive touch with
secondary fauna such as birds in the sky and butterflies.
Two additional levels were generated for the better
entertainment of pediatric patients if the user wishes to
experience another type of entertainment. Level 2 is about
collecting bones and achieving 100 points. The main level pet,
which must be cared for and fed at this level, is manipulated
by the user. The land is also in a natural style, including grass,
stones, and trees. Different triggers were used to collect objects.
Once the score is obtained, the level ends.
Fig. 12. Pathfinding Algorithm a Star. Finally, level 3 is focused on collecting clues to find the
pet. The clues are three, which are a plate of food, a bone, and
footprints. These clues are hidden on stage. This level's
scenario is different from the main level and level 2 since it is
a small city. Once the clues are found, the pet will appear,
meeting with its owner (user).
E. Phase 5: Closing
In this phase, the problems, successes, solutions,
achievement of objectives, and general feedback of the entire
process of creating the video game were evaluated. To
evaluate the aforementioned, verification tests were carried
Fig. 13. Land with Pathfinding a Star Library. out to be more specific, unit tests.

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Project verification tests were developed while adding a TABLE II. TABLE OF FUNCTIONALITY METRICS OF THE FIRST REQUISITE
component to an item. The algorithms were evaluated Name Vision recognition functionality
according to their behavior based on the pet and the player.
The respective unit tests were carried out on the entire project, How complete is the functional implementation of
Purpose
vision recognition?
but the most important or high-impact sections were:
trajectory prediction, object tracking, petting the dog, and the I was counting the missing functions detected in the
flocking algorithm. Below you can see in Table I the white Application evaluation and comparing the number of functions
Method described in the requirements specification performed
box tests performed to the trajectory prediction test section.
in the analysis stage.
The project was also tested on two different computers. “B” Number of
“A” Number of
The first uses an AMD graphics card with a 6th generation Measure, formula required X
missing functions
Intel core i5 processor, while the other computer uses a GTX and computer data functions
1660 TI video card with an 8th generation Intel core i7 0 5 1
processor.
Interpretation of
1
Metrics were carried out to know how much quality there the measured value
is in the development of the project. The ISO \ IEC 9126 Scale type absolute
standard was used. From this standard, the characteristics of A B X
functionality, reliability, and usability were applied. For what
are metrics, tables were made using the patterns required by Media type 1-(
numeric numeric numeric /
the standard, that is, the tables contain the fields of name,
numeric)
purpose, application method, formula or measure,
interpretation of the measured value, type of scale, type of Measure source Specification of requirements in the analysis stage.
measurement, source of measurement and audience. ISO/IEC 12207
Validation, Joint Review
SLCP
For the functionality metrics, tests were carried out based
Audience Analysts, developers
on the requirements detected in the simulator development
analysis stage. Table II shows the functionality metrics of one
of the requirements. TABLE III. TRAJECTORY PREDICTION RELIABILITY METRIC TABLE

In Table II, the interpretation of the measured value is 1, Name Trajectory prediction
and for the functionality metrics, if said value is one or very How many of the required test cases are covered by
Purpose
close to it, it means that this requirement meets the the trajectory prediction test plan
functionality metrics. Similarly, the reliability and usability Counting the missing functions detected in the
metrics were carried out, which can be verified in Table III, evaluation of the trajectory prediction and compare
one of the reliability metrics of the trajectory prediction Application
with the number of functions described in the
Method
functionality, and Table IV, the usability metric of the specification of requirements performed in the
interaction recognition functionality. analysis stage.
“A” Number “B” Number of
TABLE I. TRAJECTORY PREDICTION UNIT TEST TABLE of test cases in test cases X
Measure, formula
and computer data the plan required
N° Description Input data Expected output
8 9 0,8888888889
1 User takes object Left-click Successful object take
Interpretation of
The user moves Hold down the left 0,8888888889
2 Successful object take the measured value
with the object click
Scale type absolute
User launches Object dropped
3 Release left click
object successfully A B X
Gravity, the mass of Object drops Media type numeric/
4 Object falls numeric numeric
the object successfully numeric
Object collides with Gravity, the mass of The object collides and "A" comes from the test plan, "B" comes from the
5 Measure source
objects the object falls to the ground requirements specification
Object collides with Gravity, the mass of The object stays on the ISO/IEC 12207
6 Quality assurance, problem solving, verification
ceilings the object ceiling
SLCP
The object follows Gravity, the mass of The object follows the
7 Audience Developers and maintainers
the launch path object, launch angle trajectory of the launch
The object is thrown It can be seen that Table II, Table III, and Table IV are
with different force Gravity, the mass of Distance varies close to or have one as an interpretation of the measured
8
by pressing the the object, force according to force
mouse
value. The functionalities or implementations complied with
the metrics of ISO \ IEC 9126 [19]; therefore, there is quality
Gravity, the mass of The object can be
9
The object is thrown
the object, user thrown when the user
in the virtual pet simulator developed.
when the user jumps
physics jumps

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TABLE IV. USABILITY METRIC TABLE OF INTERACTION RECOGNITION scales in the EVA, FIS figures, which were explained in
Section II.
Name Interaction recognition functionality
The tests were carried out in the medical center for six
What proportion of the system functions are evident to days, in which the informed consent of the head and the parents'
Purpose
the user to have a good recognition of the interaction
respective permission with four boys and six girls were
Application Counting the functions evident to the user and compare requested. Two of them are eight years old, one nine years old
Method with the total number of functions and the other ten years old. In the girls, four were five years old,
Measure, formula “A” Total of “B” Total number one was four years old, and one was nine years old.
X
and computer obvious functions of functions
data
Each of the children attended the medical center and was
4 5 0,8
diagnosed to receive invasive medical procedures. In the first
Interpretation of four days, five pediatric patients were diagnosed with invasive
the measured 0,8 medical procedures, of which the first four were taken as a
value
control group, and from the 5th pediatric patient, they were
Scale type absolute taken as an experimental group.
A B X
The first four pediatric patients were three girls (two 5
Media type numeric/ years old and one 4 years old) and one boy (8 years old), who,
numeric numeric
numeric as mentioned above, were selected as a control group;
Measure source Requirements specification, design therefore, they did not use the simulator during the invasive
ISO/IEC 12207
medical procedures. The control group was evaluated for vital
Validation, Joint Review signs (pulse, respiratory rate) before and after the medical
SLCP
procedure, and they were given the respective pain and stress
Audience Analysts, developers
measurement scales (VAS, FIS).
Once the verification tests had been concluded and the The experimental group consisted of 6 pediatric patients,
simulator's quality had been verified, the validation tests were three girls (two 5-year-olds and one 9-year-old) and three 8, 9,
carried out. For these tests, a small medical center (medical and 10-year-old boys. This group did use the simulator during
post) was attended. A small number of 10 pediatric patients the invasive medical procedure by putting on virtual reality
were evaluated, which we detail later, who have been glasses type Vr Box 2nd Generation. Before performing the
prescribed an invasive medical procedure (injectable or serum). invasive medical procedure, when the pediatric patient had
4 children were taken as a control group. Six as a test group, it accelerated vital signs due to stress, they were given a
is known that most children feel pain and stress due to simulator and expected to interact with the pet. Once the
injectable, so four children were chosen as a control group pediatric patient was distracted, the injectable was applied.
since three were very few and what was wanted was to have Finally, once the invasive medical procedure was completed,
an experimental group of as many of the small sample as the use of the simulator was withdrawn.
possible to demonstrate the effectiveness of the pet simulator.
Having a small sample is for reasons of the covid-19 of the As was done in the control group, the pediatric patients in
year 2020 since this study was carried out during that year, in the experimental group were assessed for vital signs (heart rate,
addition, the medical field in our country is collapsing, for respiratory rate) both before and after medical procedures.
which there is not much medical attention in external clinics Finally, after carrying out invasive medical procedures,
and an enter to emergency admission is very risky for our the experimental group was given the respective pain and
health. stress measurement scales (VAS, FIS).

To verify the pet simulator's effectiveness, methods and

scales were used to measure pain and stress in patients, which
are: The Facial Image Scale (FIS) for measuring stress and the
Visual Analog Scale (VAS) for both pain and stress.
Fig. 15. Visual Analog Scale (VAS).
Vital signs (heart rate, respiratory rate) of pediatric patients
were also evaluated to have more objective results. These
signs were noted and measured before and after the medical
procedure for all pediatric patients. In this way, it was
observed how much the heart rate and/or respiratory rate
varied. Heart rate was measured by counting the pulses in the
radial artery for 1 minute. Taking the vital signs of pediatric
patients, the effectiveness of the virtual pet simulator could be
verified.
The measurement scales were given to the pediatric
patients through sheets to mark or indicate the way they felt
during the medical procedure, both those who used the
simulator or not. Below it can see in Fig.15 and Fig.16 the Fig. 16. Facial Image Scale (FIS).

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IV. RESULTS After the invasive medical procedure, Table VIII shows
that the heart rate values and the respiratory rate decrease,
A. Verification Test Results compared to the values measured before applying the
After running the virtual pet simulator, it was observed that developed virtual reality environment. Therefore, the results
the algorithms work correctly; the trajectory prediction showed that pediatric patients could distract themselves from
algorithm works at 89% since sometimes the object collided the pain and stress of the situation surrounding them, which was
with the roof of a house and got stuck there, the pet followed it the realization of the invasive medical procedure, giving more
but could not climb and reach it, the toy must be set to attention to the virtual pet simulator.
recognize whether it has a considerable difference from the
vertical coordinate of the pet, and make the toy fall. TABLE V. PEDIATRIC CONTROL GROUP VITAL SIGNS TABLE

In the movement algorithms, as for the pathfinding. A star Heart frequency Breathing frequency
algorithm, it was observed that the pet follows the character Nº Age Sex
by 90% because there is a lake in the simulator, and if the user Before After Before After
enters said lake, the pet should stop at wait for it, however, it 1 5 F 124 157 35 58
follows it under the water, it can also modify the animation, in 2 5 F 125 154 37 56
such a way if it detects that it is going to enter a water area,
the pet maintains its vertical coordinate and proceeds to swim 3 4 F 120 159 40 60
while following the player. 4 8 M 110 146 25 45

As for the flocking algorithm, the birds and butterflies were

TABLE VI. CHART OF HEART RATE IN PEDIATRIC PATIENTS
correctly added, these objects rise to the sky, and the
simulator's immersion increases. As for its function the Age Lower limit Upper limit
algorithm is at 100% because in the sky there, are no
2 age 80 130
collisions with rocks or mountains, except for the same copy
objects (neighbors); that is, the flocking algorithm works 4 age 80 120
correctly. 6 age 75 115
B. Validation Test Results 8 age 70 110
First, the results obtained in the control group are 10 age 70 110
presented. Pediatric patients' vital signs were measured before
Girls Boys Girls Boys
and after the medical procedure, as explained above. In
Table V, you can see the vital signs of pediatric patients in the 12 age 70 65 110 105
control group before and after performing the medical 14 age 65 60 105 100
procedure.
16 age 60 55 100 95
Typical heart rate values in pediatric patients are detailed 18 age 55 50 95 90
in Table VI [20].
The typical respiratory rate values in pediatric patients are TABLE VII. TABLE OF RESPIRATORY RATE IN PEDIATRIC PATIENTS
detailed in Table VII [21].
Age Lower limit Upper limit
After the medical procedure, it can be seen that in Table V 1–3 age 24 40
that pediatric patients came to present an increase in both heart
and respiratory rates. These results demonstrate that pediatric 4–5 age 22 34
patients in the control group experienced both pain and stress 6–12 age 18 30
while undergoing the invasive medical procedure. Pediatric 13–18 age 12 16
patients were also given files or surveys containing the
aforementioned scales.
TABLE VIII. TABLE OF VITAL SIGNS OF THE PEDIATRIC EXPERIMENTAL
For the VAS scale, pediatric patients marked values from 6 GROUP
to 9, which means that pediatric patients felt pain intensely Heart frequency Breathing frequency
and moderate. For the FIS Scale, pediatric patients indicated Nº Age Sex
faces from number 3 to 5, which means that all pediatric Before After Before After
patients had moderate to even severe anxiety. 1 8 M 112 90 29 18
Now the results obtained in the experimental group are 2 5 F 129 112 37 28
presented. The pediatric patients' vital signs in the 3 10 M 107 70 25 17
experimental group were also measured before and after the
medical procedure. In Table VIII, you can see the pediatric 4 5 F 131 115 37 30
patients' vital signs in the experimental group before and after 5 9 F 109 93 30 20
performing the medical procedure. 6 9 M 106 87 26 19

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 (IJACSA) International Journal of Advanced Computer Science and Applications,
Vol. 12, No. 2, 2021

V. CONCLUSIONS VII. FUTURE WORK

It was found that the application of the virtual pet simulator The simulator is still in version 1.0. It can be improved
allows distracting pediatric patients from pain and stress, since more details can be added, such as that the pet can
according to the results obtained in the tests carried out. The receive orders such as sit or play dead. It is also intended to
tests showed that the pulse and respiratory rate levels of 60% of make an improvement to level 3 by placing the clues randomly
the total pediatric patients decreased since six pediatric since the present hidden clues are static so that if the child
patients made use of the pet simulator and all six managed to plays the level several times, he will be able to memorize the
be distracted, that is to say, 100% of pediatric patients in the objects' location.
experimental group, they managed to distract themselves from
pain and stress. It is planned to test the virtual pet simulator with a larger
sample when the COVID-19 situation improves to have better
All the pulsations of pediatric patients before the medical results and check its effectiveness. It is also planned to test the
procedure exceeded 100 beats per minute; also, all pediatric simulator with other medical procedures because it was only
patients' respiratory rate exceeded 26 breaths per minute. tested with invasive medical procedures.
However, after using the pet simulator, those of the
experimental group, both their pulsation levels and their Finally, it has been thought to generate more levels to the
respiratory rates, decreased considerably. simulator; that is, it will not be oriented only for children, but
also for different types of people, creating levels of distraction
It was also found that using the pet simulator would and stress for different ages since not only children suffer pain
improve care during medical procedures for pediatric patients. and stress during medical procedures, also young adults and
Therefore, the virtual pet simulator developed allows the older adults.
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